Participant Characteristics
Claimant participants varied according to gender, compensation scheme, current employment status, and wage replacement status (see Table 1 for further details about the claimant participants). Thirteen clinicians identified as female and 13 identified as male. The clinicians ranged in experience from 1–5 years to 20 or more years. They included physiotherapists, osteopaths, a general practitioner (GP), a sports physician, a pain physician, occupational therapists, a nurse practitioner, and a psychologist (see Table 2 for further details about the clinician participants).
Themes
Four major themes were constructed through the analytic process. These are described below and summarised in Table 3.
Theme 1: It’s a Battle
Both claimants and clinicians described the experience of interacting with insurance systems as being difficult with a large administrative burden for both those under its care and those providing services for claimants. This sense of difficulty was often described by claimants using “battle” language, suggesting that both the logistical burden of the administration and the associated stress made the experience feel relentless. For example:
“The steps to get treatment were very, very difficult and denied all the time. So, I spent most of my time as if I was in a war battle trying to win little fights…. There’s a lot of emails shot off from me to be able to get treatment, which I found just so unjust.” (Claimant, Female, NSW)
Many claimants described finding initial process of opening a claim to be relatively straightforward, but subsequently finding the systems difficult to navigate, the processes required of them overly complex, and communication with the insurer to be troublesome. For example:
“The claim was accepted smoothly enough. However, my experience from then on has been very negative… in terms of personal interactions… The financial support has been there but it has been difficult to secure and difficult to maintain.” (Claimant, Female, Victoria)
Many of the claimants described the processes involved in asking the insurer for treatment, services, or wage replacement as exhausting. Processes often required multiple steps such as requests for additional documentation from providers that necessitated phone calls or further appointments. For example:
”You know, a few months pass, wait, fill out this, complete that, go to the GP now, go to the specialist now, and do this,” Claimant, Female, Victoria).
“I just felt like, instead of a three step process, it was like a 300 step process.” (Claimant, Female, Victoria)
Other claimants reported that the use of technology was a barrier for them (e.g., “If you have a bit of tech savvy then it’s OK. If you’re someone who doesn’t, then you’re in trouble because there is quite a bit of paperwork involved,” Claimant, Female, Victoria). Delays to care or financial re-imbursement that resulted from the administrative process were distressing for claimants (e.g., “It’s the length of time getting approval for things… it creates anxiety in me,” Claimant, Female, Victoria).
Clinicians reported similar experiences, explaining that the paperwork needed to access care – such as treatment plans, consultation reports, and test results – required significant time and effort to coordinate. They often felt that the administrative tasks asked of them were excessive, unnecessary, or not put to good use (e.g., “I guess it’s a lot of extra admin time that we don’t necessarily have [time for] as practitioners,” Clinician, Female, Physiotherapist). Similarly, another clinician (Female, Osteopath) described the process as “a waste of time”:
They want us to fill out a lot more questionnaires and then to either sit back and wait for an email from a case manager that you’ve never met or just sit on the phone for hours for somebody to actually read what you filled in. It was just a waste of time to be honest.
Clinicians reported they do not have enough time in their day to complete the requirements on top of their normal clinical load and, as a result, often gave up their lunch breaks (e.g., “You are trying to ring them on your lunch break,” Clinician, Female, Physiotherapist) or personal time (e.g., “It can be a lot of chasing your tail with not a lot of, I guess, good response. And therefore the hours of your [work] week blow out [and] we already don’t have a lot of spare time,” Clinician, Female, Physiotherapist).
Some clinicians suggested that the battle was not worth it, with the stress of chasing up the insurers being too much for some claimants. Indeed, some clinicians gave examples of claimant patients who chose to pay out of pocket rather than go through insurance because of the trouble:
“Between her (claimant) and I, the amount of time required to get paid slightly less by (the insurer) just made it untenable and we just couldn’t deal with them any longer,” Clinician, Female, Osteopath).
Despite finding interacting with insurers challenging, one claimant felt unable to voice their frustration because the nature of the relationship meant they were somewhat reliant on the insurer:
“When things don’t quite go the way I think they are going to go, and I’ve given my best effort to explain everything properly and people just aren’t paying attention, and then they’re being annoyed with me, I just get angry. I get pissed off. But… I express that to them because I’m relying on them.” (Claimant, Female, Victoria)
Claimants described a sense of overwhelm associated with the administrative requirements of the claim. This could frequently be seen to bring about high levels of claimant distress.
Theme 2: Life in Limbo
Many claimants reported a sense that their life was on hold (or “in limbo”) following their injury. Firstly, waiting for approval for treatment and services from their insurer frequently left people unable to access treatment, surgery, or rehabilitation services. They described a sense of helplessness or a lack of agency that accompanied delays to care. Secondly, many found the disability that accompanied their injury to be frustrating, unexpected, difficult to accept, and intrusive to life. For example:
“You are in a lot of pain, you’re worried about what’s going to happen and the doctors [have] just told you that you need this treatment. And then it can take up to a month, or in my case longer, and the whole time it’s just getting worse. And you can’t just go and pay for the treatment yourself because you might not get it paid back. And you don’t have the money spare and it’s really stressful.” (Claimant, Female, Victoria)
The delays in approvals frequently meant that continuity of care was disrupted, and claimants described a sense of not being in control of their healthcare needs. For example:
“I have these infusions for my back… These give me relief for quite some time, normally between nine and twelve months. But you can’t go and see your pain specialist and say I think I’m going to be sore in three months’ time, can we start the process? You have to wait until you are in pain and then you have to go through the whole process and then it just gets held up.” (Claimant, Male, Victoria)
Many claimants expressed a sense that life was no longer the same for them following their injury and they were not certain about their future. For some, the disability that resulted from their accident had dramatically altered their quality of life. For example:
“I feel like my leg is ruining my life. My life has changed completely… I can’t walk and I have this… pain.” (Claimant, Female, Victoria)
Claimants described both physical restriction (e.g., “There’s a lot of physical things I can’t do, so my life has been on hold, [I can’t do] any hobbies or anything physical,” Claimant, Female, New South Wales) as well as impairment in social functioning (e.g., “I avoid. That’s what it has come to at this stage. I avoid… doing any socialising,” Claimant, Female, New South Wales). The loss of function frequently seemed to impact on how people saw themselves in their roles at home. For example:
“When you can’t function… like you used to be able to function and you’re going about your daily things with your family… you’re feeling like crap.” (Claimant, Male, Victoria)
Others described a deterioration in their mood:
“When you’ve had the injury, its literally the most terrifying time of your life. You are just in the air and in a lot of pain and you’re worried about what’s going to happen.” (Claimant, Female, Victoria)
Clinicians agreed that this interruption to life and lack of autonomy for claimants created emotional distress:
“I guess they just seem worried and uncertain. Worried how that’s going to resolve.” (Clinician, GP, Male)
“I do feel that the compensable schemes tend to carry with them those high levels of distress, as there is a loss of control, that external locus of control that comes with an insurer agreeing or not agreeing to this treatment or that treatment.” (Clinician, physiotherapist, Female)
Many factors related to both the claims process and having an injury leave claimants feeling that they are not in control of their circumstances. Dealing with an injury and the subsequent disability is difficult enough for claimants to come to terms with. The additional challenges described by claimants and clinicians to access care in this time seem to rub salt in the wound and provide context for the distress that many claimants describe.
Theme 3: A Person Not a Number
In the setting of an insurance claim following injury, many claimants described a lack of individualisation in the co-ordination of their care, especially with reference to interactions with the insurer. Claimants frequently described a lack of empathy, as well as a lack of acknowledgement and validation of their circumstances, pain, and injury by insurers and, at times, by healthcare providers. One claimant described feeling like a number:
“I rang my case manager and I said, look, for you I might just be a number. But I’m a person. I’m a human being. I’m a mother … basically you are not taking care of my needs. …… I just want my needs to be looked after and that is not happening.” (Claimant, Female, New South Wales)
Another claimant similarly described the sense of de-humanisation that came with being in the system: “I felt like a little fish swimming in a sea of… people circling me. [They] knew what was going on but wouldn’t help me” (Claimant, Female, Victoria). Clinicians also described observing this in their compensable patients: “She was angry because she felt like she was a number rather than a person” (Clinician, Osteopath, Female).
Claimants perceived that the lack of individual attention, validation, or acknowledgement of their situation was part of a bigger plan by the insurer to discourage interactions with claimants or to close claims quickly (e.g., “I’m just a pathetic number on a piece of paper to you guys [and] you want to reject claims to meet your targets,” Claimant, Female, Victoria; “Their purpose seems to be intent on closing your case, not checking in with you,” Claimant, Female, Victoria). Another claimant remarked that all insurance companies behaved the same way: “They don’t want to pay. You are an inconvenience” (Claimant, Female, Victoria). Clinicians reported observing similar responses in claimants: “She didn’t feel like she was being heard by [the insurer]…She said to me…that she felt like they didn’t want her to get better and just wanted to get her off the books and be done with it” (Clinician, Female, Victoria). Another clinician felt that the lack of validation by the insurer led to claimants having to focus on their pain and injury in order to prove to the insurer that they were suffering: “I think they need to prove themselves…they perhaps focus more on what’s wrong …if that is not validated at the offset” (Clinician, Female, Victoria).
Claimants often felt that the decisions made by insurance companies regarding approval or denial of treatment or services did not reflect the request made by either the claimant or their healthcare team, and that the individual nature of their presentation was not considered. For example:
“It seems to me that the reason it was being refused was the cost of this, rather than looking at the long-term benefit. I think it could be helpful with the decisions being made, that they are based on the person.” (Claimant, Female, Victoria).
Claimants felt like it was difficult to build trust and connection with the insurer without regular check-ins from an individual case manager. They frequently expressed a desire for more check-ins in the form of phone calls. For example: “It’s not pro-active in any way. [They are] not contacting me saying how are you traveling or anything. There is never any – Can we help you with it?.” (Claimant, Male, Victoria)
Claimants frequently expressed a desire for more individualised care from the insurance company. The sense that there was a one size fits all approach and that the insurer didn’t acknowledge their individual circumstances was frustrating and upsetting.
Theme 4: Kept in the Dark
Poor communication by the insurer was frequently reported by claimants, often leaving them feeling uncertain or “in the dark” about where they stood with decisions regarding their own health or finances. They described a sense of powerlessness and uncertainty as well as an inability to find information they required. One claimant described a situation which left them needing to borrow money from family:
"Today I rang [the insurer] to tell them that my income support hasn’t come through. They are saying that [the case manager] is not working today and so we can’t do anything. We have to wait to wait until [the(case manager] is back in the office. When they are away, they can’t make the decisions and they can’t solve the problem…I need to buy some groceries…I have to borrow some money (from friends or family).” (Claimant, Male, Victoria)
There was a clear need expressed for greater information about the claims process and entitlements that claimants were eligible for (e.g., “[The] first thing was finding out the information. It wasn’t as clear-cut or easy as you would hope,” Claimant, Female, New South Wales). Claimant expectations were often that the information should be provided to them, but they reported that these expectations were frequently not met:
“I’ve had no one actually sit there and explain all of this at the start. They just gave me absolutely nothing.” (Claimant, Male, Victoria)
“I didn’t find it an easy process. There is nobody to assist you.” (Claimant, Female, Victoria)
“At the beginning it was quite frustrating because I didn’t know what I was entitled to or what I could claim… Even the physios or the people you are seeing are never sure what is and isn’t covered. Sometimes it’s as much a mystery to them as it is for the claimant.” (Claimant, Female, New South Wales)
Clinicians too felt that this lack of informational support was problematic, not only because it heightened claimant distress, but because it frequently fell to the clinicians to provide this information to claimants. This took away from valuable treatment time (e.g., “That burden of explanation falls to us, which is a time then, for our practitioners, when they’d like to be spending their appointment helping them,” (Clinician, Female, Osteopath)
Other claimants and clinicians described a sense of inconsistency with regards to the length of time for processing referrals and with decision outcomes. This gave a sense that the processes were not transparent and somewhat mysterious (e.g., “They have all these rules, which they don’t tell you about that you have to learn as you go along. For example, you can’t have physio and chiropractic, you can only have one [at a time],” Claimant, Female, Victoria). Inconsistent decision outcomes from insurers were disheartening for clinicians (e.g., “The report itself takes a significant period of time… to not get any feedback for a number of months, then… a few months later, be informed that it has been rejected, it’s a bit like… do I even bother next time?” Clinician, Male, Occupational Therapist).
Whether it was un-returned calls, unanswered emails, delayed responses to treatment requests, or difficulties with apps or other communication barriers, both claimants and clinicians felt that they frequently did not have the information that they required to do their part. A great deal of claimant distress came about from gaps in expectations that could have been mitigated by having more information about the claims process and greater communication from the insurer.